Provider Demographics
NPI:1457109605
Name:VIBAT, MARIENELL G
Entity type:Individual
Prefix:
First Name:MARIENELL
Middle Name:G
Last Name:VIBAT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2420 MARTIN RD STE 200
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94534-8610
Mailing Address - Country:US
Mailing Address - Phone:707-770-8205
Mailing Address - Fax:
Practice Address - Street 1:1119 E MONTE VISTA AVE
Practice Address - Street 2:
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95688-3009
Practice Address - Country:US
Practice Address - Phone:707-469-4610
Practice Address - Fax:707-448-1119
Is Sole Proprietor?:No
Enumeration Date:2024-05-10
Last Update Date:2025-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA372600000X
172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No372600000XNursing Service Related ProvidersAdult Companion